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Digital transformation in healthcare
Published in Edward M. Rafalski, Ross M. Mullner, Healthcare Analytics, 2022
A part of the Rush strategic plan is to serve as an anchor hospital for its regional populations and hospitals [28]. To achieve that aim, it seeks to provide capacity for transfers and offer care and wellness solutions to reduce health inequities. A thesis as leaders at Rush learned about COVID-19 was that infection and mortality difference noted between race and ethnic groups [29] were manifestations of access to care differences. A specific focus early in the pandemic was access to high intensity, high skill care such as proning for critically ill COVID-19 patients. In addition, the Rush belief in the spring and summer of 2020 was that reaching out to potential high risk populations was an effective strategy to save lives.
Dysarthria associated with hypoglossal nerve palsy and COVID-19
Published in Margaret Walshe, Nick Miller, Clinical Cases in Dysarthria, 2021
This case report describes the management of a motor speech disorder as a consequence of COVID-19. The cause of dysarthria was attributed to CNXII. Lesions of hypoglossal nerve during manoeuvring for oral intubation have been described in several studies (Cinar, Seven, Cinar, & Turgut, 2005; De Luca et al., 2020; Decavel, Petit, & Tatu, 2020; Dziewas & Lüdemann, 2002; Lykoudis & Seretis, 2012; Shah, Barnes, Spiekerman, & Bollag, 2015). Hypoglossal nerve damage may also occur as a result of proning. Decavel et al. describe a patient with COVID-19 who required prolonged prone-position ventilation with lateral flexion of the head (Decavel et al., 2020). In a post-acute care unit, this patient presented with left hypoglossal nerve paralysis and left soft palate weakness along with complete paralysis of the left vocal cord in the abducted position. The authors concluded that the prone-position ventilation could be the main aetiological factor; nevertheless, they did not report about intervention and whether the patient recovered.
Care of Critically Ill Patients with HIV
Published in Cheston B. Cunha, Burke A. Cunha, Infectious Diseases and Antimicrobial Stewardship in Critical Care Medicine, 2020
Joseph Metmowlee Garland, Andrew Levinson, Edward Wing
For patients that are mechanically ventilated for pneumonia, it is important that best practices be followed to avoid increased mortality from mechanical ventilation. In mechanically ventilated patients with pneumonia who meet current definitions for ARDS [90], a ventilation strategy using low tidal volumes of 6–8 cc/kg ideal body weight should be followed [91,92]. One large retrospective study found that lower tidal volume ventilation is independently associated with reduced mortality in HIV-infected patients with acute lung injury and respiratory failure [91]. In addition, positive end-expiratory pressure (PEEP) should be used to lower the fraction of inspired oxygen administered (FIO2) to safe levels to avoid potential oxygen toxicity [93]. If peak pressures on the ventilator remain high, or if there is difficulty with lowering the FIO2 or ventilating at targeted low tidal volumes utilizing a lung-protective strategy, alternative therapies such as extracorporeal membrane oxygenation (ECMO) should be considered. There may be a benefit to the early use of neuromuscular blockade and proning in patients who develop severe ARDS [94,95].
In memoriam of Dr. Joseph Milic-Emili
Published in Canadian Journal of Respiratory, Critical Care, and Sleep Medicine, 2022
Over the course of his storied career, Milic made myriad foundational contributions to our understanding of respiratory physiology in both health and disease. A very incomplete list of his accomplishments includes: 1) description of the cardinal features of ventilation-perfusion relationships in the lung;1,2 2) development of novel tools and concepts in the analysis of control of breathing and lung mechanics;3 and 3) dissection of the dynamic mechanical properties of the respiratory system that determine the work of breathing and flow limitation.4,5 These basic discoveries carried over into the clinical realm, helping to explain the basis of hypercapnia during treatment with high levels of oxygen, why proning improves gas exchange in intensive care unit patients, and how intrinsic PEEP increases the work of breathing along with strategies to mitigate its adverse effects in patients during spontaneous breathing or mechanical ventilation.
Ventilation management in acute respiratory failure related to COVID-19 versus ARDS from another origin – a descriptive narrative review
Published in Expert Review of Respiratory Medicine, 2021
Anissa M. Tsonas, Michela Botta, Ary Serpa Neto, Janneke Horn, Frederique Paulus, Marcus J. Schultz
In studies in patients with ARDS from another origin, prone positioning was used from 7.9% to 13.7% (Table 1 and Figure 2). In the ‘LUNG SAFE’ study, prone positioning was used in 1%, 5.5% and 16.3%, in patients with mild, moderate and severe ARDS, respectively, [48]. Duration of proning in patients with ARDS, thus far only reported in one study, named ‘APRONET’, was median 8 hours [43]. In studies in patients with acute respiratory failure related to COVID-19, prone positioning was used much more often, in up to three–quarters of patients (Table 2 and Figure 2). Clear differences in use of prone positioning between ARDS severity groups was seen in studies from Spain and from France [53,55], with five in every six patients receiving this intervention when oxygenation problems were severe [55]. In one study that reported on duration of prone positioning, sessions lasted median 13 hours [61].
MATH+ protocol for the treatment of SARS-CoV-2 infection: the scientific rationale
Published in Expert Review of Anti-infective Therapy, 2021
Paul E. Marik, Pierre Kory, Joseph Varon, Jose Iglesias, G Umberto Meduri
The core components of the MATH+ protocol include a corticosteroid (methylprednisolone), ascorbic acid (vitamin C), thiamine, anticoagulation with heparin (enoxaparin), and supplemental oxygen. Methylprednisolone 80 mg loading dose, followed by 40 mg q 12 hourly for at least 7 days and until transferred out of ICU. In patients with an increasing C-reactive protein (CRP) or worsening clinical status increase the dose to 80 mg q 12 hourly (and then 120 mg if required), then titrate down as appropriate.Ascorbic acid (Vitamin C) 3 g IV q 6 hourly for at least 7 days or until transferred out of ICU. Note caution with point-of-care (POC) glucose testing (see below).Thiamine 200 mg IV q 12 hourly for at least 7 days or until transferred out of ICU.Heparin: Unless contraindicated we suggest FULL anticoagulation (on admission to the ICU) with enoxaparin, i.e. 1 mg kg s/c q 12 hourly (dose adjust with CrCl < 30 ml/min). Unfractionated heparin is suggested with CrCl < 15 ml/min. Monitor anti-Xa activity in at risk patients (see below)Supplemental oxygen with high flow nasal canula with proning (cooperative repositioning) and epoprostenol as required. Intubation should be avoided if at all possible.